Alternative/Holistic Treatment

Attention-Deficit Hyperactivity Disorder

Behavioral techniques for managing the child with ADHD are not intuitive for most parents and teachers. To learn them, caregivers may need help from qualified health care professionals or from ADHD support groups. At first, the idea of changing the behavior of a highly energetic, obstinate, child is daunting. It is futile and damaging to try to force an ADHD child to be just like most children. It is possible, however, to limit destructive behavior and to instill a sense of self-worth that will help overcome negativity toward life, which is one of the great dangers of this disorder.

Behavioral Techniques at Home

Bringing up an ADHD child, like bringing up any child, is a process. No single point is ever reached where the parent can sit back and say, "That's it. My child is now OK, and I don't have to do anything more." Self-worth will evolve from the child's increasing ability to step back and consider the consequences of an action and then to control that action before taking it. But this does not happen overnight. A growing ADHD child is different from other children in very specific ways and presents challenges at every age.

Setting Priorities for the Parent. Parents must first establish their own levels of tolerance. Some parents are easy going and can accept a wide range of behaviors, while others can't. To help a child achieve self-discipline requires empathy, patience, affection, energy, and toughness. Some tips to help the parent are as follows:

Parents should prepare a list giving priority to those behaviors they think are most negative, such as fighting with other children or refusing to get up in the morning. The least negative behaviors on the bottom of the list should be ignored temporarily or even permanently (e.g. refusing to wear anything but red T-shirts). Certain odd behaviors that are not hurtful to the child or to others may be an indication of creative or humorous attempts to adapt (e.g. making up silly songs or drawing violent pictures). These should be accepted as part of the child's unique and positive development, even if they seem peculiar to the parent. It is important to keep in mind that no one is a saint. Loving parents who occasionally lose their tempers will not damage their children forever. In fact, non-abusive open disapproval or dismay is far less destructive to both parent and child than harboring resentment beneath a false calm. Establishing Consistent Rules for the Child. Parents must be as consistent as possible in their approach to the child, which should reward good behavior and discourage destructive behavior. Rules should be well defined but flexible enough to incorporate harmless idiosyncrasies. It is very important to understand that ADHD children have much more difficulty adapting to change than do children without the condition. (For example, the child should do homework every day but might choose to start it after a TV show or computer game.)

Managing Aggression. Some useful tips for managing aggression include the following:

Parents should try to give little attention to mildly disruptive behaviors that allow this energetic child to let off some harmless steam. The parent will also be wasting energy that will be needed when the negative behavior becomes destructive, abusive, or intentional. The use of "time-out," isolating the child immediately for a short period of time, is an effective measure for allowing both the caregiver and the child to cool down. The child should immediately (and without emotion) be removed from a situation in which he or she is endangered or is endangering others. The child should view time out as a way of cooling off and getting a distance on their behavior, not as isolation from others. To channel physical aggression and impulsivity in the ADHD toddler, the parents must teach them to use verbal responses. (A parent may need to allow verbal responses that would be unacceptable in another child.) When the ADHD child becomes older and if the verbal responses become intentionally abusive and socially undesirable, then the parent must redirect this form of aggression into more acceptable activities, such as competitive one-on-one sports, energetic music, video games, or big colorful paintings. Sometimes a parent can anticipate situations when an ADHD child is likely to misbehave, but all too often the child explodes for no apparent reason. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible. Establishing a Reward System. Children with ADHD respond particularly well to reward systems. One study reported that they performed equally well when encouraged either by a direct reward for a correct response or with the use of a system called response-cost. With this system, the child is given the reward first and allowed to keep it if their behavior remains appropriate.

Some suggested tips for rewarding the ADHD child are as follows:

Creating charts with points or stars for good behavior or completed tasks is helpful for young children. It is important to give points for even simple positive behaviors, which may be taken for granted in other children (e.g. responding happily to a change in plans, changing an obscenity to a more acceptable expletive). Rewards for any child can include playing a favorite game with the child, extending bedtime by an hour, or allowing an extra half-hour of TV. Rewards of food or gifts should be used infrequently, if at all. They can create other problems, such as being overweight, having a bad diet, or making continuous demands for objects. A reward system should rotate different types of rewards, because such children are easily bored. ADHD children respond better with small rewards promised in the short term than large rewards offered in the future. One approach that employs both short- and long-term rewards uses a system that gives the child points for specific positive behaviors. As the children accumulate points, they can use them for larger tangible rewards, such as a favorite video game or CD. Rewards should be promised only when caregivers are fairly certain they can follow through. ADHD children respond with much greater frustration than non-ADHD children to disappointment, and are likely to have a strong (and noisy) negative reaction. A parent must remember that this response is part of the ADHD child's make-up and not necessarily in their control. Improving Concentration and Attention. Research indicates that ADHD children perform significantly better when their interest is engaged. Parents should be on the lookout for activities that hold the child's concentration. One very interesting experiment reported that when children with ADHD performed word puzzles in front of a mirror that they did as well as non-ADHD children. The intent of the experiment was to focus attention back to the self and so avoid external stimuli. Some activities that help an ADHD child to focus are as follows:

Many ADHD children are particularly lured by the computer, which is a very promising tool. Although many video and computer games are based on repetitive violent events governed by hand-eye coordination, a number of games are available that offer problem-solving techniques using characters, narrative, and humor. Swimming, tennis, and other sports that focus attention and limit peripheral stimuli are often appealing. ADHD children often do not do well with team sports, although if a child is interested in baseball, positions such as pitching or catching are preferable to the outfield, where attention easily wanders. Some experts are enthusiastic about martial arts, such as Tae Kwon Do, which can offer an appropriate and controlled emotional outlet, help to focus attention, and teach self-restraint, self-discipline, and tolerance. Care should be taken to select an instructor who makes such goals a priority. Learning an instrument may be one of the best ways for an ADHD child to develop a more rhythmic and balanced sense of self. Music, even simply listening to it, is in any case is often very important for these children. (Parents may have to tolerate music that does not please them.) Management at School

Even if a parent is successful in managing the child at home, difficulties often arise at school. The ultimate goal for any educational process should be the happy and healthy social integration of the ADHD child with his or her peers.

Preparing the Teacher. Although teachers can expect that at least one student in every classroom will have ADHD, there is currently little training that prepares them for managing these children. The teacher should be prepared for the following behaviors in the ADHD child:

ADHD students are often demanding, talkative, and highly visible. Having the child sit in the front of the classroom may be helpful. Children with ADHD often require frequent reminders of or visual cues (such as posters) for rules and regulations. They frequently forget homework or miss assignments. Lack of fine motor control makes taking notes very difficult, and handwriting is often poor. Using a typewriter or computer can compensate for this. One useful skill that has helped some ADHD children is learning to type at an early age, around the third or fourth grade. Rote memorization and math computation, which require following a set of ordered steps, are often difficult. (ADHD children may do better with math concepts.) Many ADHD children respond well to school tasks that are rapid, intense, novel, or of short duration (such as spelling bees or competitive educational games), but they almost always have problems with long-term projects where there is no direct supervision. The Role of the Parent in the School Setting. The parent can help the child by talking to the teacher before the school year starts about their child's situation:

The first priority for the parent is to develop a positive, not adversarial, relationship with the child's teacher. The parent must acknowledge the teacher's situation, for he or she must deal not only with the ADHD child's behavior but also with the needs of all the other children. Frequent brief and sympathetic conversations with the teacher can be helpful and can lead to coordination of efforts, particularly if they provide reciprocal information about progress or setbacks. Finding a tutor to help after school may be helpful. Legal Issues. A number of legal issues have become both positively and negatively important in the management of ADHD in the classroom. In some districts teachers are not allowed to tell parents that they suspect their child has ADD or ADHD because of the risk of lawsuits, therefore preventing an unknowing parent from seeking help for their child. Parents sometimes report pressure by school administrators or teachers to put their children on medication or force them into special classrooms without clear educational justification. The schools, in these cases, may be acting illegally.

Special Education Programs. High-quality special education can be extremely helpful in improving learning and developing a child's sense of self worth. Many families, however, may not have appropriate programs available for them. Programs vary widely in their ability to provide quality education. Parents must be aware of certain limitations and problems with special education:

Special education programs within the normal school setting often increase the child's feelings of social alienation. If the educational strategy focuses only on abnormal behavior, it will fail to take advantage of the creative, competitive, and dynamic energy that often accompanies ADHD behavior. There is no federally funded special education category specifically targeted to ADHD. If, in fact, ADHD is as common as studies are indicating, the best approach may be to treat the syndrome as a variant of the norm and train teachers to manage these children within the context of a normal classroom.

Dietary Changes

Feingold Diet. A number of diets have been suggested for people with ADHD. The most popular is the Feingold diet, a salicylate- and additive-free diet, which requires rigorous vigilance over a child's eating habits. BHT or BHA and artificial food colors are specifically avoided. Salicylates are very common and are present in aspirin and many foods. They include apples and cider, berries (all), Chili powder, cloves, grapes, oranges, peaches, peppers (bell & chili), plums, prunes, and tomatoes. One study that reported its efficacy suggested that it might not provide enough nutritive value, although the diet provides a wide range of healthy foods to select from. Some parents report great success with this diet, although it may be difficult to impose, particularly on an ADHD child. It is certainly wise, in any case, to avoid food with artificial colors and flavors and to provide a healthy balance of fresh, natural foods.

Zinc and Fatty Acids. One 2000 study compared groups of ADHD individuals who took primrose oil (an essential fatty acid), a psychostimulant, or placebo. In assessing the results, the authors suggested that primrose oil may benefit ADHD children who are moderately deficient in zinc. In fact, in those with borderline zinc levels, a combination of zinc and primrose oil was as effective as medications in reducing ADHD symptoms. (Neither zinc nor primrose oil had any effect on children who were not zinc deficient.) It is important to note that this study needs confirmation, and testing for trace minerals, such as zinc, is not standard procedure when evaluating children suspected to have ADHD.

Neurofeedback

Neurofeedback is an experimental approach that uses electronic devices to speed up or slow down brain wave activity. In one study, children given this treatment were taught certain high-level mental activities when feedback information indicated that they were fully concentrating. They attended four 50-minute sessions, usually twice a week. At the end of the study, Ritalin use had dropped from 30% to 6%. Significant improvement was reported in inattention, impulsivity, and response time, and IQs increased by an average of 12 points. A 1999 presentation at a professional meeting reported on a study suggesting that 85% of ADHD adults and children improved after 20 sessions. This study was not reviewed by other professionals, and critics have identified methodological problems with this and other studies on neurofeedback. For example, in the 1999 study, only 20% of the subjects had an actual diagnosis of ADHD. Nevertheless, the positive results from such studies warrant further research.

Massage

Daily massage therapy helps ADHD adolescents feel happier, fidget less, be less hyperactive, and focus on tasks, according to a study published in 1998.

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Board of Editors

Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

Stephen A. Cannistra, MD, Oncology, Associate Professor of Medicine, Harvard Medical School; Director, Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center

Masha J. Etkin, MD, PhD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital

John E. Godine, MD, PhD, Metabolism, Harvard Medical School; Associate Physician, Massachusetts General Hospital

Daniel Heller, MD, Pediatrics, Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's Hospital

Paul C. Shellito, MD, Surgery, Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital

Theodore A. Stern, MD, Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital